Healthcare Facility-onset Clostridioides Difficile Infection Research Articles

Substantial reduction of healthcare facility-onset Clostridioides difficile infection (HO-CDI) rates after conversion of a hospital for exclusive treatment of COVID-19 patients

Healthcare facility-onset Clostridioides difficile infection rates substantially dropped in a Mexican hospital after its conversion to a full COVID-19 setting, despite heavy contamination of the environment the previous year. Better adherence to hand hygiene and contact precautions may help explain this finding.

Investigating the association of room features with healthcare-facility-onset Clostridioides difficile: An exploratory study.

To investigate hospital room and patient-level risk factors associated with increased risk of healthcare-facility-onset Clostridioides difficile infection (HO-CDI). The study used a retrospective cohort design that included patient data from the institution's electronic health record, existing surveillance data on HO-CDI, and a walk-through survey of hospital rooms to identify potential room-level risk factors. The primary outcome was HO-CDI diagnosis. A large academic medical center. All adult patients admitted between January 1, 2015, and December 31, 2016 were eligible for inclusion. Prisoners were excluded. Patients who only stayed in rooms that were not surveyed were excluded. The hospital room survey collected room-level data on 806 rooms. Included in the study were 17,034 patients without HO-CDI and 251 with HO-CDI nested within 535 unique rooms. In this exploratory study, room-level risk factors associated with the outcome in the multivariate model included wear on furniture and flooring and antibiotic use by the prior room occupant. Hand hygiene devices and fixed in-room computers were associated with reduced odds of a HO-CDI. Differences between hospital buildings were also detected. The only individual patient factors that were associated with increased odds of HO-CDI were antibiotic use and comorbidity score. Combining a hospital-room walk-through data collection survey, EHR data, and CDI surveillance data, we were able to develop a model to investigate room and patient-level risks for HO-CDI.

Analysis of National Healthcare Safety Network Clostridioides difficile Infection Standardized Infection Ratio by Test Type

Background: The NHSN has used positive laboratory tests for surveillance of Clostridioides difficile infection (CDI) LabID events since 2009. Typically, CDIs are detected using enzyme immunoassays (EIAs), nucleic acid amplification tests (NAATs), or various test combinations. The NHSN uses a risk-adjusted, standardized infection ratio (SIR) to assess healthcare facility-onset (HO) CDI. Despite including test type in the risk adjustment, some hospital personnel and other stakeholders are concerned that NAAT use is associated with higher SIRs than are EIAs. To investigate this issue, we analyzed NHSN data from acute-care hospitals for July 1, 2017 through June 30, 2018. Methods: Calendar quarters for which CDI test type was reported as NAAT (includes NAAT, glutamate dehydrogenase (GDH)+NAAT and GDH+EIA followed by NAAT if discrepant) or EIA (includes EIA and GDH+EIA) were selected. HO CDI SIRs were calculated for facility-wide inpatient locations. We conducted the following analyses: (1) Among hospitals that did not switch their test type, we compared the distribution of HO incident rates and SIRs by those reporting NAAT vs EIA. (2) Among hospitals that switched their test type, we selected quarters with a stable switch pattern of 2 consecutive quarters of each of EIA and NAAT (categorized as pattern EIA-to-NAAT or NAAT-to-EIA). Pooled semiannual SIRs for EIA and NAAT were calculated, and a paired t test was used to evaluate the difference of SIRs by switch pattern. Results: Most hospitals did not switch test types (3,242, 89%), and 2,872 (89%) reported sufficient data to calculate SIRs, with 2,444 (85%) using NAAT. The crude pooled HO CDI incidence rates for hospitals using EIA clustered at the lower end of the histogram versus rates for NAAT (Fig. 1). The SIR distributions of both NAAT and EIA overlapped substantially and covered a similar range of SIR values (Fig. 1). Among hospitals with a switch pattern, hospitals were equally likely to have an increase or decrease in their SIR (Fig. 2). The mean SIR difference for the 42 hospitals switching from EIA to NAAT was 0.048 (95% CI, −0.189 to 0.284; P = .688). The mean SIR difference for the 26 hospitals switching from NAAT to EIA was 0.162 (95% CI, −0.048 to 0.371; P = .124). Conclusions: The pattern of SIR distributions of both NAAT and EIA substantiate the soundness of NHSN risk adjustment for CDI test types. Switching test type did not produce a consistent directional pattern in SIR that was statistically significant.Disclosures: NoneFunding: None

Analysis of National Healthcare Safety Network Clostridioides difficile Infection Standardized Infection Ratio by Test Type

Background: The National Healthcare Safety Network (NHSN) has used positive laboratory tests for surveillance of Clostridioides difficile infection (CDI) LabID events since 2009. Typically, CDIs are detected using enzyme immunoassays (EIAs), nucleic acid amplification tests (NAATs), or various test combinations. The NHSN uses a risk-adjusted, standardized infection ratio (SIR) to assess healthcare facility-onset (HO) CDI. Despite including test type in the risk adjustment, some hospital personnel and other stakeholders are concerned that NAAT use is associated with higher SIRs than EIA use. To investigate this issue, we analyzed NHSN data from acute-care hospitals for July 1, 2017, through June 30, 2018. Methods: Calendar quarters where CDI test type was reported as NAAT (includes NAAT, glutamate dehydrogenase (GDH)+NAAT and GDH+EIA followed by NAAT if discrepant) or EIA (includes EIA and GDH+EIA) were selected. HO-CDI SIRs were calculated for facility-wide inpatient locations. We conducted the following 2 analyses: (1) Among hospitals that did not switch their test type, we compared the distribution of HO incident rates and SIRs by those reporting NAAT versus EIA. (2) Among hospitals that switched their test type, we selected quarters with a stable switch pattern of 2 consecutive quarters of each of EIA and NAAT (categorized as EIA-to-NAAT or NAAT-to-EIA). Pooled semiannual SIRs for EIA and NAAT were calculated, and a paired t test was used to evaluate the difference in SIRs by switch pattern. Results: Most hospitals did not switch test types (3,242, 89%), and 2,872 (89%) reported sufficient data to calculate an SIR, with 2,444 (85%) using NAAT. The crude pooled HO CDI incidence rates for hospitals using EIAs clustered at the lower end of the histogram versus rates for NAATs (Fig. 1). The SIR distributions, both NAATs and EIAs, overlapped substantially and covered a similar range of SIR values (Fig. 1). Among hospitals with a switch pattern, hospitals were equally likely to have an increase or decrease in their SIRs (Fig. 2). The mean SIR difference for the 42 hospitals switching from EIA to NAAT was 0.048 (95% CI, −0.189 to 0.284; P = .688). The mean SIR difference for the 26 hospitals switching from NAAT to EIA was 0.162 (95% CI, −0.048 to 0.371; P = .124). Conclusions: The pattern of SIR distribution for both NAAT and EIA substantiate the soundness of the NHSN’s risk adjustment for CDI test types. Switching test type did not produce a consistent directional pattern in SIR that was statistically significant.Funding: NoneDisclosures: None

Impact of an automated hand hygiene monitoring system combined with a performance improvement intervention on hospital-acquired infections.

Hand hygiene adherence has been associated with reductions in nosocomial infection. We assessed the effect of improvements in electronically measured hand hygiene adherence on the incidence of hospital-acquired infections. This quasi-experimental study was conducted in a 555-bed urban safety-net level I trauma center. The preintervention period was January 2015 through June 2016. Baseline electronic hand hygiene data collection took place from April through June 2016. The intervention period was July 2016 through December 2017. An electronic hand hygiene system was installed in 4 locations in our hospital. Performance improvement strategies were implemented that included education, troubleshooting, data dissemination, and feedback. Adherence rates were tracked over time. Rates of hospital-acquired infections were evaluated in the intervention units and in control units selected for comparison. The intervention period was subdivided into the initial and subsequent 9-month periods and were compared to the baseline period. Electronically measured hand hygiene rates improved significantly from baseline to intervention, from 47% 77% adherence. Rates >70% continued to be measured 18 months after the intervention. Interrupted time series analysis indicated a significant effect of hand hygiene on healthcare facility-onset Clostridioides difficile infection rates during the first 9 months of the intervention. This trend continued during the final 9 months of the intervention but was nonsignificant. No effects were observed for other hospital-acquired infection rates. Implementation of electronic hand hygiene monitoring and performance improvement interventions resulted in reductions in hospital-onset Clostridioides difficile infection rates.

The Effect of Clostridioides difficile Diagnostic Stewardship Interventions on the Diagnosis of Hospital-Onset Clostridioides difficile Infections

Public reporting of Clostridioides difficile infection (CDI) using laboratory-identified events has led some institutions to revert from molecular-based tests to less sensitive testing modalities. At one academic medical center, researchers chose to use nucleic acid amplification test alone in CDI diagnosis with institutional protocols aimed at diagnostic stewardship. A single-center, quasi-experimental study was conducted to introduce and analyze the effects of various diagnostic stewardship interventions. In April 2017 an order report was created to inform providers of patients' recent bowel movements, laxative use, and prior Clostridioides difficile (CD) testing (Intervention 1). In November 2017 nursing staff were empowered to not send nondiarrheal stools for testing (Intervention 2). In February 2019, an interruptive alert was implemented to prevent testing that was not indicated (Intervention 3). CD testing rates and healthcare facility-onset CDI (HO-CDI) rates were compared before and after the interventions using one-way analysis of variance (ANOVA). At baseline, testing for CD after 3 days of admission was performed at mean ± standard deviation of 15.9 ± 1.7 tests/1,000 patient-days. After Intervention 1, it decreased to 12.1 ± 1.1 tests. This further decreased to 10.6 ± 0.8 after Intervention 2 and to 8.1 ± 0.1 after Intervention 3 (p < 0.001). HO-CDI cases per 10,000 patient-days declined from 12.7 ± 1.4 cases at baseline to 10.7 ± 1.2 after Intervention 1, to 8.7 ± 2.4 after Intervention 2, and to 5.8 ± 0.2 after Intervention 3 (p = 0.03). A multidisciplinary approach optimizing electronic health record support tools and leveraging nursing education can reduce both testing and HO-CDI rates while using the most sensitive testing modality.

Potential for the current National Healthcare Safety Network (NHSN) >3 days after admission definition of laboratory-identified, healthcare-facility-onset, Clostridioides difficile infection (HO-CDI) to overestimate rates.

Healthcare-facility-onset C.difficile LabID events are defined as positive stool samples collected >3 days after hospitalization. Using a definition of >72 hours, we found that 84 of 1013 cases (8.3%) identified as C. difficile LabID events were collected between 48 and 72 hours after admission.

2414. Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility-Onset Clostridioides difficile Infection in High-Risk Patients

BackgroundStudies suggest oral vancomycin prophylaxis may be effective in preventing Clostridioides difficile infection. These studies are limited by their retrospective design, reliance on local clinical practice patterns, lack of intervention standardization, and limited risk stratification. We sought to evaluate the effectiveness of oral vancomycin for the prevention of healthcare facility-onset CDI (HCFO-CDI) in high-risk patients.MethodsWe conducted a randomized, prospective, open-label study at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina between October 2018 and April 2019. Admitted high-risk patients (defined as: ≥ 60 years of age, hospitalized ≤ 30 days prior to the index hospitalization and received systemic antibiotics during that prior hospitalization and currently receiving systemic antibiotics) were randomized 1:1 to either oral vancomycin (dosed at 125 mg once daily while receiving systemic antibiotics and continued for 5 days post completion of systemic antibiotics [OVP]), or no prophylaxis. The primary endpoint was incidence of HCFO-CDI. Secondary endpoints included incidence of community-onset healthcare facility-associated CDI (CO-HCFA-CDI), development of VRE colonization after receiving OVP, and adverse effects and cost of OVP.ResultsA total of 100 patients were evaluated, 50 patients in each group. Baseline and hospitalization characteristics were similar in each group. No incidents of HCFO-CDI were diagnosed in the OVP group compared with 6 (12%) in the no prophylaxis group (P = 0.03). CO-HCFA-CDI was not observed in either group. No patients developed new VRE colonization with only 1 patient reporting mild gastrointestinal side-effects to OVP. A total of 600 doses of OVP were given during the study, with each patient receiving an average of 12 doses. Total acquisition cost of OVP was $728.25, $60.69 per patient.ConclusionOVP was highly effective in preventing HCFO-CDI. OVP was well tolerated with no apparent risk for VRE colonization. Further prospective investigation is warranted to determine the impact and cost-effectiveness of routine use of OVP in high-risk patients.Disclosures All authors: No reported disclosures.

84. Evaluation of the NHSN Standardized Infection Ratio (SIR) Risk Adjustment for HO-CDI in Oncology and ICU Patients in General Acute Care Hospitals

BackgroundThe NHSN healthcare-facility onset Clostridioides difficile infection (CDI) standardized infection ratio (SIR) is used to compare hospital quality and set hospital reimbursement but inadequate risk adjustment could penalize hospitals unnecessarily. We hypothesized that general hospitals with large oncology and/or ICU populations were not fully adjusted in the 2015 NHSN acute care hospital CDI Laboratory-Identified (LabID) event prediction model and SIRs would be affected.MethodsWe validated a negative binomial regression HO-CDI event prediction model identical to the 2015 published model and used FY2016 data from eight general hospitals in California to test our hypothesis. We compared HO-CDI events and SIR values, with and without oncology/hematopoietic stem cell transplant or ICU unit events, patient-days, admissions, bed counts, and adjustment parameters included.ResultsSeven major teaching and one nonteaching general acute care hospitals were included (see Table). Eight had oncology/hematopoietic stem cell transplant units; seven had ≥43 ICU beds (median: 134; interquartile range [IQR]: 84–161). The median facility unmodified FacWideIn SIR was 1.23 [IQR: 1.15, 1.29]. Removal of oncology unit data resulted in a 15% median facility decrease in HO-CDI events (IQR: 14%, 21%) and −8% median facility decrease in SIR (IQR: −2%, −14%). Removal of ICU unit data resulted in a 22% median facility decrease in HO-CDI events (IQR: 16%, 26%) and 97% median facility increase in SIR at each facility (IQR: 78%, 105%).ConclusionThe ICU bed adjustment in the 2015 NHSN SIR is a powerful correction that fully adjusted for ICU HO-CDI events at all hospitals in the study. However, the lack of risk adjustment for oncology/hematopoietic stem cell transplant unit HO-CDI events suggests that the current model unfairly penalizes general acute facilities, many of which also provide specialized oncologic care. Thus, the model needs to be re-adjusted to account for this important specialty care population in general acute care facilities. Disclosures All Authors: No reported Disclosures.

2349. C. diff-erent results: Eliminating Inappropriate Stool PCR Tests Through an Interdisciplinary Infection Prevention and Mirobiology Collaboration

BackgroundDiagnosis of Clostridium difficile infection (CDI) is based on symptoms and laboratory results. Distinguishing between CDI vs colonization or antibiotic-associated diarrhea is challenging. Widespread adoption of a highly sensitive real-time nucleic-acid amplification assay for toxin B DNA (Xpert CD assay, Cepheid) by US hospital-based microbiology labs has increased the challenge, resulting in overreporting of healthcare facility-onset CDI. Excess testing is inevitable in hospitals with EPIC electronic medical record (EMR) that incorporate best practice alerts (BPAs) prompting for C. difficile testing (CDT) when loose stools are charted by nursing staff.MethodsBeginning October 1, 2018 microbiology and infection prevention (IP) staff at our 650 bed teaching hospital in central IL agreed to partner on a diagnostic stewardship effort to engage providers on potentially unnecessary or inappropriate CDTs. All stool samples sent to lab for CDT are held pending IP review. The IP review tool provides a guide for EMR review of contributing factors in diarrhea, including patient history, medications (e.g., laxatives, stool softeners), nutrition (e.g., tube feeds), symptoms (abdominal pain), and labs (e.g., serum creatinine, WBC count). Inappropriate CDT was defined as test of patients receiving pro-motility treatment, without signs of infection.ResultsBetween October 1, 2018 and December 31, 2018, 383 CDT were ordered on inpatients. 196 were requested within 3 days of admission, and 187 were requested on beyond day 4. 56.6% (107/187) HO-CDTs were deemed inappropriate and canceled; 80 HO-CDT were deemed appropriate. 18.8% (15/80) of HO-CDTs were positive. Compared with October 1 - December 31, 2017, HO-CDI cases decreased by 66.7% (1.0 - 15/45) over the same period in 2018.ConclusionA 66.7% reduction in HO-CDI (vs. FY2017 cases) was seen in the first 3 months following adoption of a team-based (IPs, microbiology lab staff and MD director), CDT diagnostic stewardship intervention employing EMR review and patient provider engagement (RNs and MDs). Opportunities identified during the first 90 days of CDT stewardship: (a) Lack of provider awareness of pro-motility therapies; (b)inappropriate prompting for CDT generated by the EPIC EMR. Disclosures All authors: No reported disclosures.

Effectiveness of Oral Vancomycin for Prevention of Healthcare Facility-Onset Clostridioides difficile Infection in Targeted Patients During Systemic Antibiotic Exposure.

Limited retrospective data suggest prophylactic oral vancomycin may prevent Clostridioides difficile infection (CDI). We sought to evaluate the effectiveness of oral vancomycin for the prevention of healthcare facility-onset CDI (HCFO-CDI) in targeted patients. We conducted a randomized, prospective, open-label study at Novant Health Forsyth Medical Center in Winston-Salem, North Carolina, between October 2018 and April 2019. Included patients were randomized 1:1 to either oral vancomycin (dosed at 125 mg once daily while receiving systemic antibiotics and continued for 5 days postcompletion of systemic antibiotics [OVP]) or no prophylaxis. The primary endpoint was incidence of HCFO-CDI. Secondary endpoints included incidence of community-onset healthcare facility-associated CDI (CO-HCFA-CDI), incidence of vancomycin-resistant Enterococci (VRE) colonization after receiving OVP, adverse effects, and cost of OVP. A total of 100 patients were evaluated, 50 patients in each arm. Baseline and hospitalization characteristics were similar, except antibiotic exposure. No events of HCFO-CDI were noted in the OVP group compared with 6 (12%) in the no-prophylaxis group (P = .03). CO-HCFA-CDI was identified in 2 patients who were previously diagnosed with HCFO-CDI. No patients developed new VRE colonization, with only 1 patient reporting mild gastrointestinal side effects to OVP. A total of 600 doses of OVP were given during the study, with each patient receiving an average of 12 doses. Total acquisition cost of OVP was $1302, $26.04 per patient. OVP appears to protect against HCFO-CDI during in-patient stay in targeted patients during systemic antibiotic exposure. Further prospective investigation is warranted.

Novel Visualization of Clostridium difficile Infections in Intensive Care Units.

Accurate and timely surveillance and diagnosis of healthcare-facility onset Clostridium difficile infection (HO-CDI) is vital to controlling infections within the hospital, but there are limited tools to assist with timely outbreak investigations. To integrate spatiotemporal factors with HO-CDI cases and develop a map-based dashboard to support infection preventionists (IPs) in performing surveillance and outbreak investigations for HO-CDI. Clinical laboratory results and Admit-Transfer-Discharge data for admitted patients over two years were extracted from the Information Warehouse of a large academic medical center and processed according to Center for Disease Control (CDC) National Healthcare Safety Network (NHSN) definitions to classify Clostridium difficile infection (CDI) cases by onset date. Results were validated against the internal infection surveillance database maintained by IPs in Clinical Epidemiology of this Academic Medical Center (AMC). Hospital floor plans were combined with HO-CDI case data, to create a dashboard of intensive care units. Usability testing was performed with a think-aloud session and a survey. The simple classification algorithm identified all 265 HO-CDI cases from 1/1/15-11/30/15 with a positive predictive value (PPV) of 96.3%. When applied to data from 2014, the PPV was 94.6% All users "strongly agreed" that the dashboard would be a positive addition to Clinical Epidemiology and would enable them to present Hospital Acquired Infection (HAI) information to others more efficiently. The CDI dashboard demonstrates the feasibility of mapping clinical data to hospital patient care units for more efficient surveillance and potential outbreak investigations.

Reduced Clostridioides difficile Tests Among Solid Organ Transplant Recipients Through a Diagnostic Stewardship Bundled Intervention.

Background Clostridioides difficile infection (CDI) is a frequent complication of solid organ transplantation, especially in the early post-transplantation period. Overdiagnosis of CDI is likely common in hospitals using nucleic acid amplification testing (NAAT), potentially leading to unnecessary iatrogenesis and cost. Recently, multiple studies have shown that computerized clinical decision support (CCDS)-based interventions can significantly reduce inappropriate C. difficile testing and healthcare facility-onset CDI events across hospitals and health systems. We aimed to determine if a CCDS-based intervention could reduce C. difficile testing and surveillance infection events among recent solid organ transplant recipients, a population at high risk for CDI. We also sought to determine the safety of the CCDS intervention.Material/MethodsQuasi-experimental census-adjusted interrupted time-series analyses were performed retrospectively to examine testing and CDI events pre- and post-intervention. Mortality and readmissions rates were also examined.ResultsA significant 33% relative reduction in tests and a nonsignificant trend towards fewer CDI events were observed following the intervention, without significant differences in mortality or 30-day readmission. A review of patients with positive C. difficile NAATs after prevented tests revealed no specific adverse events attributable to a possible delay in CDI diagnosis.ConclusionsCCDS may be a helpful and safe adjunctive strategy to reduce unnecessary testing in accordance with guideline recommendations among solid organ transplant recipients.

Use of whole-genome sequencing to guide a Clostridioides difficile diagnostic stewardship program.

Whole-genome sequencing (WGS) has yielded new insights into the transmission patterns of healthcare facility-onset Clostridioides difficile infection (HO-CDI). WGS results prompted a focused diagnostic stewardship program, which was associated with a significant and sustained decrease in HO-CDI at large, urban hospital.

Universal screening for Clostridioides difficile in a tertiary hospital: risk factors for carriage and clinical disease

ObjectivesThe role of asymptomatic carriers in Clostridioides difficile infection (CDI) epidemiology is not fully understood. Our aim was to evaluate CD carriage prevalence on admission, associated risk factors, and the risk of developing CDI. MethodsA 10-week surveillance program for CD carriage of all medical patients admitted to the Sheba Medical Centre was implemented, utilizing an admission rectal swab PCR. Healthcare facility-onset CDI (HO-CDI) was recorded and divided into HO-CDI diagnosed in CD carriers and non-carriers. ResultsA total of 4601 admissions were recorded in 3803 patients; 2368 patients had technically analysable rectal swabs, of whom 81 (3.4%) were CD carriers. A multivariate logistic regression model showed that previous hospitalization, old age (>85 years) and low Norton scores were significant independent predictors of CD carriage. Carriers were more likely to receive antimicrobial therapy during hospitalization than non-carriers were. The incidence of HO-CDI in non-carriers was 4.6 cases per 10 000 patient-days; the incidence of HO-CDI in carriers was 76.7 cases per 10 000 patient-days (RR 16.6, 95% CI 4.0–69.1, p .002). ConclusionsIn a prospective study, the rate of CD carriage on admission in medical patients was 3.4%. CD carriers were older, frailer, and more likely to have been hospitalized recently. HO-CDI incidence was significantly higher among CD carriers than among non-carriers, with at least a third of CDI in screened patients developing in carriers. Targeted screening of high-risk groups for CD carriage should be further considered.

No Impact of Probiotics to Reduce Clostridium difficile Infection in Hospitalized Patients: A Real-world Experience.

We assessed the effectiveness of a Lactobacillus probiotic on rates of health care facility–onset Clostridium difficile infection (HO-CDI) in patients receiving antibiotics. A total of 1576 patients were evaluated. There was no difference in the HO-CDI incidence between those who received probiotics and those who did not (1.8% vs 0.9%; P = .16).

Effect of copper-impregnated linens on multidrug-resistant organism acquisition and Clostridium difficile infection at a long-term acute-care hospital.

Copper-impregnated surfaces and linens have been shown to reduce infections and multidrug-resistant organism (MDRO) acquisition in healthcare settings. However, retrospective analyses of copper linen deployment at a 40-bed long-term acute-care hospital demonstrated no significant reduction in incidences of healthcare facility-onset Clostridium difficile infection or MDRO acquisition.

EPOP-149 - Impact of a Nurse Testing Guide on the Accuracy of Clostridium Difficile Location Onset Classification

Background: The use of healthcare facility-onset Clostridium difficile infection (CDI) data in financial incentive and penalty programs has made the timely identification and testing of CDI patients essential for appropriate classification within the National Healthcare Safety Network (NHSN). NHSN classifies location onset based on specimen collection date; community-onset (CO) on admission day one, two, or three, and healthcare facility-onset (HO) on day four or later. Delay in the identification and testing of potential CDI patients can cause CO-CDI to be misclassified as HO-CDI. To improve the screening process and reduce time to testing one four-campus regional health system implemented a Clostridium difficile nurse testing guide. The guide outlined criteria for testing as three or more watery or loose stools not related to laxatives and allowed nurses to collect a specimen and send for testing without a provider order.

Overreporting healthcare-associated C. difficile: A comparison of NHSN LabID with clinical surveillance definitions in the era of molecular testing

Clostridium difficile infection (CDI) is the most common healthcare-associated gastrointestinal infection. Hospitals are required to report cases of healthcare facility-onset CDI (HO-CDI) using the National Healthcare Safety Network's CDI laboratory-identified (LabID) event definition. The aim of this study was to determine the extent of potential over-reporting due to the exclusion of important clinical data within LabID reporting definitions. In 2015, retrospective chart review was performed on 212 HO-CDI cases reported from a large urban medical center. Cases had positive polymerase chain reaction test for the C. difficile toxin B gene from an unformed stool specimen collected >3 days after admission and >8 weeks after most recent LabID event. Cases were categorized into "clinical surveillance" groups: community-acquired infection, recurrence/relapse, asymptomatic colonization, colonization with self-limited symptoms, possible HO-CDI, and probable HO-CDI. Of the infections, 13.6% were community acquired, 2.8% were recurrent/relapse, 1.9% were asymptomatic colonization, 18.4% were symptomatic colonization, 38.7% were possible HO-CDI, and 24.5% were probable HO-CDI. Within 24 hours of testing, 34.1% of patients had received a stool softener and/or laxative. Laxative use and failure to identify community-onset infection may contribute to misclassification of HO-CDI. Only 62% of reported cases met clinical surveillance criteria.

National Healthcare Safety Network laboratory-identified Clostridium difficile event reporting: A need for diagnostic stewardship

We describe the proportion of health care facility-onset Clostridium difficile infection (HO-CDI) National Healthcare Safety Network laboratory-identified events at our facility that were deemed nontrue HO-CDIs. Reasons included testing in a patient without significant diarrhea or with recent laxative use, or delayed testing. Standardized infection ratios using only true HO-CDI in the numerator were improved compared with publically reported standardized infection ratios. A prioritization matrix identifies which clinical services could benefit most from directed diagnostic stewardship interventions.